Pre-Existing Condition Insurance Plan (PCIP) HIPAA Authorization Form

Forms and Documents

Document Name	Status
Form CMS-10428 PCIP Authorization Form Form and Instruction	New
CMS-10428.Supporting Statement Part A.docx Supporting Statement A	2012-03-14

IC Document Collections

IC ID	Document Title	Status
201588	PCIP Authorization Form Form and Instruction	New

ICR Details

OMB Control No: 0938-1161	ICR Reference No: 201203-0938-010
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Pre-Existing Condition Insurance Plan (PCIP) HIPAA Authorization Form
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 03/22/2012
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/21/2012
	Date Received in OIRA: 03/19/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2012	6 Months From Approved
Responses	2,100	0	0
Time Burden (Hours)	525	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Unless permitted or required by law, the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule prohibits CMS' PCIP program (a HIPAA covered entity) from disclosing an individual's protected health information without a valid authorization. In order to be valid, an authorization must include specified core elements and statements. CMS will make available to PCIP applicants and enrollees a standard, valid authorization to enable beneficiaries to request the disclosure of their protected health information.

Emergency Justfication: The Department of Health and Human Services (HHS) Centers for Medicare & Medicaid Services, Center for Consumer Information and Insurance Oversight is requesting emergency clearance by the Office of Management and Budget for this new collection package. This new package is being requested as a result of CMS, in its administration of the PCIP program, serving as a covered entity under the Health Insurance Portability and Accountability Act (HIPAA). Without a valid authorization, the PCIP program is unable to disclose information, with respect to an applicant or enrollee, about the status of an application, enrollment, premium billing or claim, to individuals of the applicant's or enrollee's choosing. This is especially critical given the population that the PCIP program represents is comprised of individuals with pre-existing conditions who may be incapacitated and need an advocate to help them apply or receive benefits under our plan. CMS is at risk and public harm is reasonably likely to result if we are not able to begin using a HIPAA Authorization Form immediately. This risk includes (1) not being able to provide PCIP applicants and enrollees Authorized Representatives with information about their eligibility or enrollment and (2) CMS being determined to be out of compliance with HIPAA. Due to the urgency and short time frames associated with this requirement, CMS does not have sufficient time to follow the normal notice and comment periods associated with the normal OMB approval process. Therefore, we are requesting an emergency review and approval for this information collection request.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 1101 Name of Law: Temporary High Risk Health Insurance Pool Program
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 1101 Name of Law: temporary high risk health insurance pool program

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 14807	03/13/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
PCIP Authorization Form	CMS-10428	Pre-Existing Condition Insurance Plan (PCIP) HIPAA Authorization Form

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	2,100	0	2,100	0	0	0
Annual Time Burden (Hours)	525	0	525	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new information collection request.

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Annual Cost to Federal Government: $20

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 03/19/2012

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